grandround Pres perthes
Download
Report
Transcript grandround Pres perthes
Legg-Calve-Perthes
Disease
FIRM 1 GRANDROUND
PRESENTERS: DR. MAINA/DR. ONDARI
FACILITATOR: DR. T. MOGIRE
01/08/2013
Georg Perthes (1869-1927)
First described by
Karel Maydl
Epidemiology
Incidence 1-4/10,000
Age 4 - 10years; average 7 yrs
As early as 2yrs as late as teens
Boys : girls 4:1
Bilateral 10-12%
No evidence of inheritance
Common in Caucasians; rare in black races
Etiology
Idiopathic
Past theories
Infection, inflammation, trauma,
congenital
Most theories involve vascular
compromise
Pathophysiology
Rapid growth occurs in relation to devt of blood
supply
Interruption of blood supply results in necrosis,
removal of necrotic tissue, and its replacement with
new bone.
Bone replacement may be so complete and perfect
that completely normal bone may result
The adequacy of bone replacement depends on
Age of the patient
Congruity of the involved joint
Sources of blood supply
Up to 4years
Metaphyseal vessels
Retinacular vessels
Ligamentum teres – scanty
4 to 7 years
Metaphyseal vessels ceases
Above 7years
Vessels in ligamentum teres have developed
Pathology
Goes through stages which may last 3 to 4 years
Stage1
Ischaemia and bone death, cartilage thickens
Stage 2
Revascularization and repair
Dead marrow replaced by granulation tissue
Bone revascularized and new bone laid down
Dead bone resorbed, replaced by fibrous tissue, fragmentation
Stage 3
Distortion and remodelling
Restoration of femoral archtecture or collapse
Femoral head displaces laterally in relation to acetabulum
Classification
Waldenstrom classification
Catterall classification
Salter and thompson classification
Herring classification
Caterall classification
Based on amt of involvement of femoral
epiphysis
Group I
<1/2
Group II
Up
of head involved ,
to half of head. Some collapse of central portion
Group III
>1/2
of head involved with sclerosis, fragmentation
and collapse of head
Group IV
Entire
epiphysis involved
Caterall “head-at-risk” signs
Associated with poor results
lateral subluxation (most important)
calcification
Gage's
lateral to the epiphysis
sign: V shaped defect laterally
metaphyseal cysts
horizontal growth plate
Caterall “head-at-risk” signs
metaphyseal cysts
Gage's sign
Salter and thompson classification
Describes extent of subchondal fracture in the
superolateral portion of femoral head
Type A - <50% of femoral head
Type B - >50% of femoral head
can be observed radiographically earlier and more
readily tan caterall classification
Can be applied early in course of dz to determine
management
Herring classificatin/lateral pillar
Based on degree of collapse of lateral pillar during fragmentation
stage
Goup A
No collapse, no progressive flattening
Group B
<50% collapse
Group C
>50% collapse
Ritterbusch 1993
Has the highest predictive value and interobserver reliability
Bilateral involvement
More severe dz than unilateral
Boys and girls equally affected
Independent event
Bone age delayed in perthes disease
Examination
Short stature
Delayed
bone age
Early
Decreased
ROM
Antalgic gait
Late
Decreased
ROM of motion from acetabular impingement
Disuse atrophy of thigh muscles
Leg lenght descrepancy
Trendelenburg gait
Investigations
Blood tests
haemogram, ESR, CRP
Imaging
Plain X-rays
Hip U/S
Bone scintigrpahy
MRI
Dynamic arthrography
Assess spherity of femoral head
Hinge abduction
Bilateral perthes
Skeleta survey as part of work-up
Song et al MRI findings on widened
medial joint space
Initial stage
Overgrowth of cartilage
Fragmentation stage
Overgrown cartilage with widened
true medial joint space
Healing stage
Widened true medial joint space
Treatment
Goals of tratment
Maintain femoral head spherity –
containment
Avoid
severe degenerative arthritis
Guided by
Age
Severity
Limitation in ROM
Treatment cont.
Initial Mx determined by sympts severity
Analgesia
Modification of activities
Bedrest and short period of traction
Wheelchair/crutch walking discouraged
Preserve abduction
Determine bone age
Treatment: Two main choices
Conservative
Pain
control
Gentle exercises
Regular re-assessment
Avoid sport and strenous activities
Containment
Hold
hips widely abducted in cast/brace >1yr
Operation
Varus
osteotomy of femur
Innominate osteotomy of pelvis
Both
Herring Guidelines to treatment
Children <6years
Symptomatic treatment
Children >6years; bone age more imp than chronological age
Bone age at or <6yrs
Lateral pillar A or B/ caterall I and II
Lateral pillar C/ Caterall III and IV
Bone over 6years
Herring A and B/Caterall I and II
Abduction brace or osteotomy
Herring C/Caterall III and IV
Symptomatic treatment
Outcome unaffected by treatment
Children 9yrs and older
Except in very mild cases, operative containment is the treatment of
choice
oseoclast-osteoblat interaction
Prognostic features
Age
Gender
Herrings lateral pillar classification
Salter and thompson grade B worse prognosis
Caterral classification grade
Caterral “head-at-risk” signs
Girls have worse prognosis
Classification grade
<6yrs; good regardless of treatment
6-9years; not always satisfactory with containment
>10yrs; questionable benefit from containment, poor prognosis
The five signs carry worse prognosis
Others
Body weight, decreased ROM